Military Health Care: Families Face Challenges Accessing Care for Special Needs, Defense Has Not Reviewed Coverage
Fast Facts
Military families rely on TRICARE's Extended Care Health Option program to obtain health care services for their special needs children. However, this program may not be meeting enrollees' needs because its coverage limit has remained the same since 2009. Its benefits also may not be on par with those of other programs, like Medicaid.
The Department of Defense plans to review this program's benefits, including how they compare to those of certain Medicaid programs. But the department hasn't set goals for this review or a time frame for completing it.
We recommended it do so.
A U.S. military uniform and medical stethoscope laying on top of an American flag with wood blocks that spell out HEALTH.
Highlights
What GAO Found
The Department of Defense (DOD) offers eligible military families with special needs dependents coverage for additional services beyond what is covered by TRICARE health plansthrough the TRICARE Extended Care Health Option (ECHO) program and its ECHO Home Health Care (EHHC) benefit. EHHC provides coverage for additional services to enrollees who are homebound with medically complex conditions. Together, ECHO and its EHHC benefit provide coverage for habilitative services (provided to help individuals keep, learn, or improve skills and functioning for daily living) and respite care (in which a provider temporarily cares for the individual with special needs). EHHC also covers skilled nursing care.
TRICARE Programs Providing Health Care Services to Military Families with Special Needs, 2024
Military families with special needs dependents also may be eligible for coverage for home- and community-based services, such as skilled nursing care and respite care, through their state Medicaid program. GAO found that 14 of the 24 programs in seven states it reviewed offered coverage for all three services, and some programs covered more respite care than currently provided by ECHO.
GAO also found that military families may experience challenges accessing services through ECHO, which DOD has taken some steps to address. For example, of the 734 authorizations approved for respite care services from 2022 through 2024, less than one third were used. According to ECHO case managers, this lower usage is partly due to the lower number of respite care hours the program covers. Officials from the Defense Health Agency (DHA)—the agency within DOD responsible for managing ECHO—reported taking steps to increase ECHO respite care hours from 16 to 32 hours per month. GAO also found that ECHO’s coverage limit—$36,000 per enrollee, per calendar year—has remained the same since 2009. As such, the coverage limit may not have kept pace with increased health care costs. Additionally, while DHA officials said that the agency plans to compare ECHO benefits with those offered through Medicaid, it has not set goals or a timeline to complete this review. Assessing ECHO’s coverage limit and establishing goals and a timeline for its planned review of ECHO benefits would help DHA determine whether the program is effectively meeting enrollees’ needs.
Why GAO Did This Study
Individuals with special health care needs navigate complicated health care systems. Military families with special needs children may face additional challenges due to frequent moves across military installations. To address the needs of these military families, DOD provides coverage for health care services through the TRICARE ECHO program. A House report included a provision for GAO to review certain services available to military families.
This report describes coverage for nursing care, habilitative services, and respite care available to military families with special needs children through (1) ECHO and (2) Medicaid. It also examines (3) challenges military families may face when seeking access to these services through ECHO and steps DOD has taken to address any challenges.
GAO reviewed DOD and Medicaid program policies and documents in seven states with high active-duty military member presence. GAO also interviewed DOD officials, TRICARE representatives, state Medicaid officials, and stakeholder organizations representing military families and the special needs community.
Recommendations
GAO is making two recommendations to DOD to (1) assess the TRICARE ECHO coverage limit; and (2) establish goals and a timeline to conduct its planned review of ECHO benefits. DOD agreed with the second recommendation, but disagreed with the first recommendation, citing average ECHO utilization amounts from 2024. As discussed in the report, GAO continues to believe that assessing the coverage limit in light of future inflation and enrollee needs will help DHA determine if any change is necessary.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Defense Health Agency | The Director of the Defense Health Agency should assess and document its assessment of TRICARE's coverage limit for the ECHO program; and take steps to adjust the coverage limit as appropriate. (Recommendation 1) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Defense Health Agency | The Director of the Defense Health Agency should establish goals and a timeline to implement the planned review of TRICARE ECHO benefits with those offered by state Medicaid HCBS waiver programs, and to share findings from this review with Congress. (Recommendation 2) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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